Purpose/Goal

The purpose of this module is to provide comprehensive information pertaining to basic medical asepsis and isolation precautions for easily transmitted diseases.

At the completion of this module, you will be able to:

• Explain how to minimize a health care provider’s risk for acquiring a communicable disease.
• Identify the elements of the chain of infection.
• Discuss factors that influence the transmission of health care associated infections (HAIs)
• Describe the procedures for cleaning, disinfecting and sterilizing items used in patient care. 
• Identify standard and transmission precautions.
• Differentiate among standard, contact, droplet, and airborne precautions.
• Identify the standard precautions for blood and body fluids and body-substance isolation as specified by the Centers for Disease Control and Prevention (CDC).
• Explain the rationale for isolation precautions in hospitals.
• Identify where to find policies and procedures for exposure within an organization or agency.
• Identify the nurse and patient implications related to isolation.
• Define and correctly pronounce terms specific to infection control.
• Explain latex sensitivity including implications related to occupational skin disorders.
• Explain the value of Evidence-Based Research for infection control in the work setting.
• Practice infection control in a controlled practice or simulation environment.

Communicable disease 

A communicable disease is an infectious disease that can be transmitted from one person to another. Measles, mumps, rubella, influenza, methicillin resistant Staphylococcus aureus, hepatitis and tuberculosis are examples of communicable diseases.  Health care professionals are at risk to exposure to a number of infectious diseases. However, there are a number of vaccines available to prevent disease. It is imperative health care providers keep their recommended vaccinations up-to-date.  Check this website for the CDC guidelines regarding vaccinations. 

https://www.cdc.gov/vaccines/adults/rec-vac/hcw.html

Screening for tuberculosis is required for health care providers. Use your internet browser to locate the CDC publication factsheet for recommendations regarding tuberculosis testing for health care providers.  

Chain of Infection  

The chain of infection consists of six elements. Each of the elements is linked to the next element in a specific sequence. If all elements are not present, or the elements are not linked in the sequence as demonstrated below the patient will not experience an infection. This gives health care providers an opportunity to break the cycle and prevent the patient from experiencing an infection.

The causative agent is also known as the infectious agent or the etiologic agent. In other words, the causative agent is a microorganism that is capable of producing an infection. Causative agents include bacteria, viruses, protozoa, and fungi. Virulence is the ability of a microorganism to cause disease. For all patients, prompt identification of an infection, isolation and treatment are essential. Patients who are immunocompromised are at a greater risk for developing an infection. Therefore, health care providers must be extremely vigilant when caring for these patients. Careful assessment and early detection of an infection are key to preventing further complications for the patient. In addition to the use of standard precautions, a protective environment might be required.

The reservoir is the place where microorganisms thrive. Humans, animals, insects, water, and organic material are examples of common reservoirs. Reservoirs which might lead to Health Care Associated infections (HAIs) include the hands of health care providers, patients, equipment and the environment. The most common way for an infection to spread from one person to another is through human contact.

Common reservoirs in the human body include the respiratory, gastrointestinal, reproductive and urinary tracts, as well as blood and tissue.

Portal of exit

The portal of exit is the route by which microorganisms exit the reservoir on their way to a susceptible host. Portals of exit include breaks in the skin, blood, and the respiratory, gastrointestinal, reproductive, and urinary tracts.   

Mode of transmission

The mode of transmission is the method by which microorganisms are transmitted to another human. The three modes of transmission are direct contact, indirect contact, and airborne.

Kissing, touching, biting, and sexual intercourse are examples of direct contact. Poor hand hygiene is the major route of transmission in the health care setting. Other examples of direct contact are the transmission of microorganisms from equipment in the environment such as stethoscopes, blood pressure cuffs and bedside commodes.

The spread of microorganisms by droplets (larger than 5 microns) is another method by which direct transmission occurs. Droplet spread occurs when the source and host are in near proximity (1 m/3 feet). Coughing, sneezing and spitting can project microorganisms from the source to the eyes, nose or mouth of the host and thus, spread microorganisms.

Indirect transmission requires either a vehicle or vector. Vehicles that transmit microorganisms include handkerchiefs, toys, eating utensils and surgical equipment, as well as water, food, serum and blood. Vector transmission occurs when an animal or an insect bites or stings a person which then transmits the microorganism. The West Nile virus and the avian bird flu are examples of diseases spread by vector transmission.

Airborne transmission is the spread of microorganisms by dust particles, or small droplets (less than 5 microns). The microorganisms become airborne and then enter the host through a portal of entry (usually the respiratory system). 

Portal of entry

The portal of entry is the route by which microorganisms enter the host. Portals of entry include skin, blood, and the respiratory, gastrointestinal, reproductive, and urinary tracts. Frequently, microorganisms enter the host’s body by the same route they exited the source.

Susceptible host

The susceptible host is an individual who has a high risk of infection. A number of factors place patients at risk for infection. Patients at risk are the very young or the very old, those who are immunosuppressed, are poorly nourished, or have chronic illnesses.

Antibiotic resistant Staphylococcus aureus and vancomycin-resistant enterococci and other organisms pose serious health concerns, especially for hospitalized patients. Breaking the chain of infection through prevention is an effective strategy to minimize an increase in the number of antibiotic resistant organisms.

Evidence-Based Practice

Health-care associated infections (HAIs) are infections that a patient acquires while receiving care in a health care setting. As many as 2 million patients acquire an HAI each year which results in pain and suffering, prolonged hospitalization, time lost from work and increased cost of health care. Additionally, it is estimated that every year as many as 75,000 patients die as a result of a HAI.

Common sites for HAIs are:

• the urinary tract due to unsterile catheterizations, repeated catheterizations, improper management of the urinary drainage system; 
• surgical wounds due to breaks in sterile technique, improper skin preparation, contamination during dressing changes, contaminated antiseptic solution;
• the respiratory tract due to poor technique when suctioning the airway, use of contaminated respiratory equipment;
• the blood stream due to improper technique when providing intravenous therapy, including IV medication administration.

The majority of HAIs are preventable. The simple task of performing careful hand hygiene has shown to reduce the risk of HAIs.  Performing hand hygiene in the presence of the patient and family promotes trust and is a way to serve as a role model for others. Some professional licensing boards have taken an active role in reducing the risk for HAIs by requiring licensees to complete continuing education about infection control at the time of renewal.

Hand Hygiene

The term "hand hygiene" refers to both handwashing with an antimicrobial or plain soap and water as well as alcohol-based products such as gels, foams, and rinses. Alcohol-based products contain an emollient that does not require the use of water. According to the most up-to-date infection-control guidelines from the Centers for Disease Control and Prevention, in the absence of visible soiling of hands and when contamination from spore-forming organisms such as Clostridium difficile is unlikely, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbicidal activity, reduced drying of the skin, and convenience. Overall, hand hygiene remains the most important measure for preventing the transmission of microorganisms.

Upon arrival to work, the caregiver should routinely inspect their hands for breaks or cuts in the skin or cuticles.  Open areas provide a portal of entry for organisms. If lesions are found, a dressing should be applied prior to providing care to patients.

Perform hand hygiene before caring for a patient and after contact with anything in the room. Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Perform hand hygiene immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites.

Avoid artificial nails, which harbor microorganisms, and keep nails trimmed to one quarter of an inch when caring for patients. In addition, avoid wearing rings whenever possible. If the areas under fingernails are soiled, clean them with the fingernails of the other hand or with an orangewood stick. Wash hands with soap and water when hands are visibly soiled.

Soap and water handwash

Turn on the water and adjust it to a comfortable, warm temperature.

Wet the hands, keeping the hands lower than the elbows.

Apply 3 to 5 mL of soap to the hands, coating all surfaces.

Rub the hands vigorously together, working up a lather, for at least 15 seconds.

Rinse thoroughly, pointing the fingers down to allow water to run off the hands.

Dry the hands from the fingers to the wrist.

Turn off the water with a clean paper towel.

Alcohol-based handrub

Apply 3 to 5 mL (per manufacturer) of antiseptic gel to the palm of one hand.

Rub the hands together, coating all surfaces, and rub vigorously until the gel disappears and the hands are dry.

Waste Management

Disposing properly of patient-care equipment contaminated with blood, body fluids, secretions, and excretions is essential for preventing the spread of microorganisms to other patients and environments. Do not use reusable equipment for the care of other patients until it has been cleaned and reprocessed appropriately.  For example, reusable bedpans and blood pressure cuffs should be disinfected prior to use on another client. 

Most facilities have procedures in place for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces. Be certain these procedures are followed.

There are two levels of asepsis: medical asepsis and surgical asepsis. Health care providers use medical asepsis to break the chain of infection. Diligent use of medical asepsis significantly reduces the occurrence of HAIs. Examples of medical asepsis include handwashing, cleaning and disinfection.

Cleaning is the removal of foreign matter from objects. Most, but not all, of the microorganisms are removed. Cleaning involves water, detergent and scrubbing. Soiled objects are cleaned before they are disinfected or sterilized. To manually clean soiled objects the following steps are taken:

1. Don protective eye wear and utility gloves
2. Use cold water to rinse the object-hot water will cause the organic material to coagulate making removal difficult
3. After rinsing, use soap and water to scrub the object
4. Rinse the object again
5. Apply friction using a brush to the remaining grime
6. Rinse object and dry it thoroughly
7. Follow agency policy to clean the sink and the equipment

Disinfection is the removal of almost all microorganisms. It does not destroy spores. There are 2 levels of disinfection: surface disinfection and high-level disinfection. High level-disinfection is used for medical equipment such as endoscopes. Chemical agents such as alcohols, formaldehyde, chlorines and ammonium are used for high-level disinfection.

Sterilization is the removal of all microorganisms, including viruses and spores. Moist heat (use of an autoclave), is used for items that can tolerate high pressure and a temperature above the boiling point.  Ethylene oxide (ETO) gas destroys microorganisms and spores.  ETO gas is very effective for heat-sensitive items, but is toxic humans. In most health care settings, employees in a central processing unit have advanced education in disinfection and sterilization and provide these services for the facility.

The use of boiling water is appropriate for sterilization in the home setting because it is inexpensive and convenient. However, this technique is not capable of destroying all bacterial spores and viruses.  This method is not utilized in the health care setting.

Health care facilities have established policies about when cleaning, disinfecting and sterilization are to be used. Reusable items can be placed into one of three categories depending on the risk of infection associated with its use. Critical items are ones that enter the patient’s body or vascular system and pose a high risk of infection. Sterilization is required for critical items. Semicritical items are ones that come in contact with mucous membranes or non-intact skin. Semicritical items require either high-level disinfection or sterilization. Non-critical items come in contact with intact skin. See the table below for examples of each category:

Occupational exposure to blood-borne pathogens continues to be a hazard for health care providers. Often this exposure occurs when the health care provider recaps a needle or during the administration of intravenous therapy.  The Occupational Safety and Health Administration (OSHA) is a federal agency whose purpose is to protect employees from unsafe working conditions.  OSHA provides recommendations to prevent needle stick injuries.

• Use needleless safety devices as much as possible
• Avoid recapping a needle used to administer a medication
• Avoid breaking or bending a used needle
• Don’t force a needle into the sharp’s container
• Dispose needles and needless devices into a puncture-proof, leak-proof sharps disposal container immediately after use of devices
• Never place a used needle into a uniform pocket or leave it anywhere in the patient’s room.

Patients who self-inject medications at home should be instructed how to dispose of used needles. Community services are available to assist patients with used needle disposal. Check the US Environmental Protection Agency (EPA) or the Federal Drug Administration (FDA) websites for more information.

Dispose of blood, body fluids, suctioned fluids, and excretions by flushing them into the sewage system or per agency protocol. When dumping potentially infectious fluid, be especially careful not to splash it on your uniform or on the surrounding environment. Dispose of the emptied container in the appropriate receptacle.

Consider all specimens potentially infectious, and collect them in a container that closes securely. Avoid contamination of the outside of the container. Most agencies require placing the specimen in a plastic bag labeled as "Biohazard" before transporting.

Linens

Hold soiled linens away from the body to prevent contamination of clothes.  Linens soiled with blood, body fluids, secretions, and excretions should be transported in a leak-resistant bag.  Avoid shaking or tossing linens, as this can spread micro-organisms to other patients and environments. Also, to prevent transmitting infection, do not place soiled linens on the floor. If clean linens touch the floor or any unclean surface, immediately place them in the soiled linen container.

Personal Protective Equipment

Personal protective equipment (PPE) such as gloves, gowns, masks, and eyewear may be necessary to prevent the transmission of infectious materials found in blood, body fluids, secretions, and excretions.

Gloves

 

Disposable gloves are made from a variety of polymers such as latex, nitrile rubber, polyvinyl chloride and neoprene. They are available as unpowered or powdered. Corn starch can be used to permit ease of application. Both nonsterile and sterile gloves are used by health care providers when delivering care to patients. Latex and nitrile mold to the hand. Nitrile gloves are preferred for tasks that require a high degree of dexterity. Vinyl gloves are acceptable when the risk to exposure to pathogens is low and a high degree of dexterity is unnecessary.

Use of latex gloves places both the health care provider and the patient at risk for a latex allergy.  Powdered latex gloves create an additional risk because the latex allergen adheres to the powder. The powder is released into the air and then can be inhaled into the lungs.

Wear clean, nonsterile gloves when touching blood, body fluids, secretions, excretions, and contaminated items.  Apply gloves prior to touching mucous membranes and non-intact skin. Gloves should fit comfortably and not be reused. The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves.

Perform hand hygiene until the product disappears and the hands are dry.

Select the appropriate size glove.

Holding the glove at the opening, slip the fingers into the glove and pull tight.

With the gloved hand, hold the second glove at the opening and slip the ungloved fingers into the glove and pull tight.

Pull gloves to the wrists of both hands.

Remove the gloves by grasping the cuff of the other gloved hand.

Avoiding skin contact, roll the glove inside out and place it in the palm of the gloved hand.

Grasp the glove on the inside of the cuff and pull inside out.

Dispose of the gloves.

Perform hand hygiene.

Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.

Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient.  Wash hands immediately to avoid transferring micro-organisms to other patients or environments.

Wear sterile gloves when following the principles of surgical asepsis for keeping an area/object free of all microorganisms. Thorough handwashing must be performed before donning sterile gloves and after discarding the gloves.

Masks

Masks provide barriers to infectious materials and are often used with other personal protective equipment such as gowns and gloves. When worn properly, masks and eye protection provide protection for the mouth, nose, and eyes during procedures where there is a potential for droplets or splashing of blood or body fluids. In addition to these standard precautions, special precautions are mandated by the CDC for airborne, droplet, and contact involving highly transmissible diseases such as measles, varicella, tuberculosis, influenza, mumps, rubella, wound infections, scabies, and many other infectious diseases.

Procedure masks are flat/pleated and affix to the head with ear loops. They are used for any nonsterile procedure.

Surgical masks come in two basic types: One type is affixed to the head with two ties, conforms to the face with the aid of a flexible adjustment for the bridge of the nose, and may be flat/pleated or duck-billed in shape. The second type of mask is pre-molded, adheres to the head with a single elastic band, and has a flexible adjustment for the bridge of the nose.

All masks have some degree of fluid resistance, but those approved as surgical masks must meet specified standards for protection from penetration of blood and body fluids.

Some masks have ties and some have elastic to secure the mask to the face. One is flexible and one is molded.

Both have a flexible nose piece that is adjusted by pinching at the bridge of the nose.

Place and hold the mask over the nose, mouth, and chin while stretching the band over the ear or tying the ties behind the head and at the base of the neck.

Adjust the mask so it is snug with no gaps. The mask should not be touched or readjusted during use.

After properly removing and disposing of gloves, carefully remove the elastic from the ear or untie the mask from the back of the head, bottom tie first.

  

Dispose of the mask.

Perform hand hygiene.

Respirators

Respirators are used for case-specific procedures where particulates and secretions create a high risk of infection for the healthcare worker. Agencies typically have special procedures for these devices and provide special training and clearance for use.

Current OSHA standards require that respirators used for airborne precautions for suspected and confirmed pulmonary tuberculosis (TB) minimally filter 95% of 0.3 µm-size particles. The N95 respirator and the HEPA respirator meet these requirements. All personnel who care for patients with suspected and confirmed pulmonary TB must wear an N95/HEPA respirator when entering the patient's room. An N95 respirator mask is intended to be used for protection against solids. The N95 is extremely durable, has a soft and comfortable inner surface, an adjustable nosepiece, and secure head straps to provide proper fit. A person using an N95/HEPA respirator must be fit-tested before use. Check with agency policy about respirator use for infection control.

Face and Eye Protection

Face and eye protection provide a barrier to infectious substances and are typically used in conjunction with other personal protective equipment such as gloves, gowns, and masks. The type of face and eye protection chosen depends on the specific work conditions and potential for exposure. There are a variety of devices including goggles, shields, safety glasses, and even full-face respirators. Personal knowledge of potential exposure is essential for making an informed decision about the right face and eye protection. Eyeglasses prescribed for vision correction and contact lenses are not considered eye protection. For complete and proper protection, it's also important to evaluate the combination of protection recommended for the specific work situation. For example, some masks may not work with various goggles or shields. Likewise, a full-face respirator may provide adequate protection without additional personal protective equipment.

Grasping the ear or head pieces of the appropriate device, spread and slowly apply the device over the ears.

Adjust for comfort as needed.

Remove using ungloved hands. Grasp the ear pieces and lift away from the face.

Discard disposable devices in the appropriate receptacle. If the device is designed to be reused, process it according to agency protocol.

Goggles

Goggles are available with direct or indirect venting. Direct-vented goggles have the potential for allowing the penetration of splashes and are not as reliable as indirect-vented goggles. Goggles must fit snugly to provide adequate protection from splashes, sprays, and respiratory droplets.

Face Shields

Face shields are sometimes used as an alternative to goggles. Because the shield has a larger surface area, it provides protection to other facial areas. Face shields do not fit snugly against the face, making them vulnerable to splash and spray going under the shield. Shields are typically used with other forms of protection and should not be considered the best protection.

Safety glasses

Safety glasses are excellent for providing impact protection. However, they do not protect adequately from splash, spray, and respiratory droplets. Thus, they are not typically used for infection-control purposes.

Gowns

A clean, nonsterile gown is adequate for protecting skin and preventing soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Most patient interactions do not require the use of a gown. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible and wash hands to avoid transferring micro-organisms to other patients or environments.

Select the appropriate type and size of gown.

With the gown opening in the back, pull the arms through the sleeves one at a time and pull it over the shoulders. Secure at the neck and waist.

If the gown is disposable and designed to be removed quickly, the gloves may be removed with the gown and rolled together to prevent contamination.

If not using a breakaway gown, untie the waist tie before removing the gloves. Remove gloves and with ungloved hands, untie the gown at the neck and pull it away from the shoulders. Roll it into a bundle while avoiding contact with the outside of the gown.

Dispose of the gown.

Perform hand hygiene.

In order to reduce the spread of microorganisms apply and remove PPE in the proper order.

Donning equipment

1. Perform hand hygiene immediately before donning equipment.
2. Put on the gown by placing the arms into the sleeves, then tie the gown at the neck, overlap the gown in the back and tie at the waist.
3. Put on the face mask by placing it over the nose and tying strings at back of the head. If glasses are worn, place the rim of the face mask under the glasses to prevent the glasses from fogging.
4. Put on eyewear/goggles/face shield
5. Apply gloves and pull cuff of gloves over the gown sleeve.

Removing equipment when not using a break away gown

1. Remove all PPE at the doorway of the room before exiting.  The exception is a respirator mask which should be removed outside the room after closing the door.
2. Remove the gloves first since they are the most soiled piece of equipment. Remove the first glove by pinching it at cuff and invert glove as it is removed. Then, remove the second glove by sliding fingers under the cuff and pulling it off and pulling it inside out.
3. Remove eyewear.
4. Remove the gown by untying the ties, taking care to avoid touching the soiled surface of the gown and rolling the gown inside out.
5. Remove the mask by handling only the ties. The front of the mask is considered to be contaminated. The bottom ties should be undone first to prevent the mask from falling onto the front of the uniform. If using a respirator mask, remove it after leaving the room.     
6. Perform hand hygiene.  If the hands become visibly soiled during the removal of the PPE, perform hand hygiene before proceeding.

Latex and latex-free equipment

Latex sensitivity and latex allergies are of concern to healthcare providers and patients. This is partly due to the potential for high exposure to latex gloves and medical supplies that contain latex.

Healthcare providers and patients who have a sensitivity or allergy to kiwifruit, papayas, avocados, bananas, potatoes, or tomatoes should be screened carefully as they have a higher chance of having a sensitivity or allergy to latex.

The three most common reactions to latex products are:

• Irritant contact dermatitis
• Allergic contact dermatitis (delayed hypersensitivity)
• Latex allergy

Irritant contact dermatitis

Rubber latex products often cause irritant contact dermatitis. Areas of the skin, usually the hands, become dry, itchy, and irritated. This reaction is caused by skin irritation from using gloves and possibly by exposure to other workplace products and chemicals. The reaction can also result from repeated handwashing and drying, incomplete hand drying, use of cleaners and sanitizers, and exposure to powders added to the gloves. Irritant contact dermatitis is not a true allergy.

Allergic contact dermatitis

Allergic contact dermatitis results from exposure to chemicals added to latex during harvesting, processing, or manufacturing. These chemicals cause skin reactions similar to those caused by poison ivy. The rash usually begins 24 to 48 hours after contact and may progress to oozing skin blisters or spread away from the area of skin touched by the latex.

Latex allergy

The most serious reaction to latex is a latex allergy. The protein in rubber can cause an allergic reaction in some people. Also, when healthcare workers change gloves, the protein/powder becomes airborne and could be inhaled into the respiratory tract. Reactions usually begin within minutes of exposure to latex, but can occur hours later and produce a variety of symptoms. Mild reactions to latex involve skin redness, hives, and itching. More severe reactions may involve symptoms such as runny nose, sneezing, itchy eyes, scratchy throat, asthma (difficult breathing, coughing spells, and wheezing) and anaphylactic shock.

Treating latex allergy

Once a healthcare provider or patient has been identified with a latex sensitivity or allergy, precautions must be taken to prevent exposure. Replacing latex-containing gloves and supplies with non-latex items is essential.

Preventing a latex allergy

• Use non-latex gloves for activities that do not involve exposure to infectious materials.
• Request non-latex gloves that provide protection against infectious materials.
• Avoid oil-based creams or lotions while using latex gloves. This may cause break down of the gloves.
• Wash hands with a mild soap, and dry hands completely after using gloves.
• Request reduced-protein, powder-free gloves if your facility supplies latex gloves.
• Recognize symptoms of a latex allergy.

When a patient has been identified with a latex sensitivity or allergy, it is important that the entire healthcare team be aware. A latex-free cart supplied with latex-free items should be used for all care to prevent exposing the patient to latex.

Cough Etiquette

In 2013, the Centers for Disease Control recommended that respiratory hygiene/cough etiquette be incorporated into infection control as one component of standard precautions. These should be instituted in the health care setting at the first point of contact with a potentially infected person to prevent the transmission of all respiratory infections. The recommended practices have a strong evidence base.

Respiratory hygiene/cough etiquette applies to anyone entering a healthcare setting (patients, visitors, and staff) with signs or symptoms of illness (cough, congestion, rhinorrhea, or increased production of respiratory secretions.) whether diagnosed or undiagnosed. The components of respiratory hygiene/cough etiquette include:

• covering the mouth and nose during coughing and sneezing
• using facial tissues to contain respiratory secretions, with prompt disposal into a hands-free receptacle
• wearing a surgical mask when coughing to minimize contamination of the surrounding environment
• turning the head when coughing and staying at least 3 feet away from others, especially in common waiting areas
• disinfecting hands after contact with respiratory secretions

Be sure to educate patients and families about these new guidelines. Also, observe standard and droplet precautions and hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection.  Posting signs in languages appropriate for the population served, will reinforce these instructions to patients and accompanying family members or friends reminding them of these recommendations.

Standard and transmission-based precautions

There are currently two tiers of CDC precautions to prevent transmission of infectious agents: standard precautions and transmission-based precautions.

Standard precautions

Standard precautions are applied to the care of all patients in healthcare settings, regardless of suspected or confirmed presence of an infectious agent. Standard precautions are used with blood, blood products, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes. This infection prevention practice includes: hand hygiene; use of gloves, gown, mask, and face shield; respiratory hygiene/cough etiquette; and safe injection practices. The selection of PPE depends upon anticipated blood, body fluid, or pat.

Transmission-based precautions

The second tier addresses isolation precautions, which are based on the mode of transmission of a disease. There are three categories of transmission-based precautions: contact precautions, droplet precautions, and airborne precautions. These are used when the route of transmission is not completely interrupted by standard precautions. Transmission-based precautions are for patients who have highly transmissible pathogens.

Contact precautions

Direct contact refers to the care and handling of contaminated body fluids.

Indirect care refers to the transfer of an infectious organism through a contaminated intermediate object, such as contaminated instruments or hands of healthcare workers.

Contact precautions include the use of personal protective equipment: gloves and gowns. These patients should also be in a private room to prevent cross-contamination. Examples of infections contact precautions are instituted for include VRE, MRSA, C. difficile, wound infections, and herpes simplex.

Droplet precautions

Droplet precautions are used when a disease is transmitted by large droplets expelled into the air and travels 3 to 6 feet from the patient.

This type of precaution requires the use of a surgical mask when within 3 feet of the patient, proper hand hygiene, and some dedicated care equipment. The mask should be applied prior to entering the patient’s room. Examples of a patient who requires droplet precautions include those who have influenza or Mycoplasma pneumonia.

Airborne precautions

Airborne precautions are used with patients who have diseases that are transmitted by smaller droplets. These droplets remain airborne for longer periods of time. This form of isolation requires a negative airflow. This airflow filters air through a high-efficiency particulate air (HEPA) filter and then directs the air to the outside of the facility.

This type of precaution requires the use of an N95 respirator each time healthcare workers enter the patient’s room. This mask should be applied prior to entering the room. This type of mask must be fitted properly prior to use. An example of a diagnosis that requires airborne precautions is pulmonary tuberculosis.

 With all of these types of transmission-based precautions, certain basic principles should be followed.

• Thoroughly perform hand hygiene prior to entering and leaving the room of a patient in isolation.
• Properly dispose of contaminated supplies and equipment according to agency policy.
• Apply knowledge of mode of infection transmission when using personal protective equipment.
• Protect all persons from exposure during transport of an infected patient outside of the isolation room.
• Cohorting is the placement of patients who are infected with the same organism in the same room. It can be used during outbreaks of infections. However, when single private rooms are available this is the preferred room assignment. Consultation with a member of the infection control committee is recommended prior to making the decision to corhort patients.

Protective Environment

The protective environment is designed for patients who have a high risk of infection because they are immunocompromised (patients who are receiving chemotherapy, have major burns or have undergone transplants or who are neutropenic).  This environment reduces the risk of environmental fungal infections. These patients require a private room with positive airflow and HEPA filtration for incoming air. Patients should wear a mask if they are out of the room during times of construction in the area. They are also not allowed to have fresh flowers or potted plants in their rooms.

 

Evidence-Based Research on Infection Control

Study 1: Determinants of hand hygiene noncompliance in intensive care units

Study data

Alsubaie, S., bin Maither, A., Alalmaei, W., Al-Shammari, A. D., Tashkandi, M., Somily, A. M., Alaska, A., & BinSaeed, A. A. (2013). American Journal of Infection Control, 41, 131-135.

This observational study was carried out in five intensive care units in Saudi Arabia to determine the factors associated with hand hygiene noncompliance. The World Health Organization’s “Five Moments for Hand Hygiene” procedure was used as a basis for the observations. The noncompliance rate was 58%. Factors associated with noncompliance included job title, working in the a.m. shift, working in the pediatric intensive care unit, and performance of hand hygiene before patient contact. Hand hygiene compliance was highest among therapists and technicians due to few patient interactions, while physicians had the lowest compliance rate. Nurses have a responsibility to advocate for patients by reminding noncompliant health care providers to perform hand hygiene.

Conclusions

The study identified many important factors that may be targeted during hand hygiene initiatives, including hand hygiene education and training for medical staff, a focus on daytime shifts, pediatric units, and reminders for hand hygiene prior to initial patient contact. The location and ease of access to alcohol-based hand rub dispensers was also noted as a modifiable factor.

Study 2: Motivating Process Compliance through Individual Electronic Monitoring: An Empirical Examination of Hand Hygiene in Health Care

Study data

Staats, B., Dai, H., Hofmann, D. & Milkman, K. (2016).  Management Science, 63(5). 1563-1585.

This study investigated the effectiveness of electronic monitoring to increase hand hygiene compliance within the health care setting.  The study used radio frequency identification-based systems on 71 hospital units to monitor for appropriate hand washing.  Initially, there was found to be a large positive increase in compliance.  However, over a three and one half year period of continued observation, hand hygiene compliance gradually decreased. In areas where the monitoring devices had been discontinued, the follow-up revealed that compliance rates had decreased to levels below those prior to the initiation of the study.

Conclusions

The authors concluded that although individual electronic monitoring can dramatically increase hand hygiene compliance, there needs to be sustained managerial commitment for the compliance rates to continue. 

The authors concluded that alcohol-based foam, gel, or wipes provided significant reductions in viral counts on hands.

Study 3: Evaluation of isolation compliance using real time video in critical care

Study data

Oey, M., Armellion, D. & Farber, B. (2015).  Open Forum Infectious Diseases 2(1). 1101. 

In two intensive care units (ICU), cameras viewed patient rooms and recorded health care professional adherence with recommended personal protective equipment (PPE) based upon Centers for Disease Control and Prevention (CDC) precautions to reduce disease based transmission.  Personnel were recorded for one week, 24 hours a day for adherence to Airborne, Droplet, and Contact Precautions.  The interactions were streamed to an independent auditor who assessed for the use of an N95 respirator for Airborne Precautions, a surgical mask for Droplet Precautions and a gown plus gloves for Contact Precautions. There were 16,571 interactions observed of health care professionals with patients in isolation.  Compliance rates for Contact, Droplet and Airborne Precautions were 10%, 16% and 11% respectively.  The overall rate of compliance with CDC PPE recommendations in the ICU was 11%.

Conclusions

Compliance with CDC PPE recommendations is low in the acute care setting.

Documentation

Documentation is an essential component of patient care. Not only does it provide information about the care provided and the status of the patient, it also communicates information to other healthcare workers to help assure both quality and continuity. Additional uses of documentation include: use in legal proceedings, reimbursement, education, research, and quality assurance.

The format used for documentation varies from agency to agency. Health care personnel have a professional responsibility to demonstrate proficiency with the employers selected format. Use only approved abbreviations and make sure all documentation is clear, concise, and legible. Maintain privacy and confidentiality of patient information at all times.

Mandatory compliance with the privacy rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was introduced in 2003 to help ensure that patient information is kept confidential and to give patients more control over their personal healthcare information and who has access to it. HIPAA originally required written consent for disclosure of all patient information. Because this process lead to delays in providing timely patient care, the act was revised. Now healthcare providers are only required to notify patients of their privacy policy and to make a reasonable effort to obtain written acknowledgment of this notification.

All healthcare providers, including students, have a legal and ethical obligation to follow HIPAA regulations. In clinical settings, students should only gather the information from the patient’s medical record that they need to provide safe and efficient care. Any written material students prepare and share, submit, or distribute must exclude the patient’s name, room number, date of birth, medical record number, and any other identifiable demographic information.

Types of documentation

Documentation for infection control should include the following and any additional information pertinent to a procedure:

• infection control measures used
• clean or sterile gloves used
• if the patient has a latex sensitivity or allergy
• the patient’s response to care
• any specimens and cultures obtained and sent to lab
• disposal precautions used
• type of isolation protocol used

Common Questions in Infection Control

1. Are prescription eyeglasses or contact lenses an acceptable form of eye protection?    
   No. Neither eyeglasses nor contact lenses provide enough coverage to prevent infectious disease (splashes) via ocular exposure and transmission.    
   
2. How long can fingernails be?    
   Nails should extend no more than ¼ inch past the nail bed. Special care should be taken to clean the underside thoroughly. Artificial nails should be avoided.    
   
3. Are artificial nails acceptable in health care facilities?    
   Evidence shows that healthcare workers wearing artificial nails carry more pathogens on their nails than other health care workers. The effectiveness of hand hygiene is reduced. The Centers for Disease Control and Prevention, the Joint Commission, and the American Association of Operating Room Nurses recommend prohibiting the wearing of artificial nails.    
   
4. How far can a virus-laden droplet travel and still be a potential source of infection?    
   It can travel up to 3 feet in any direction and still be infectious.    
   
5. When without a facial tissue, is it appropriate to “sneeze into your sleeve”?    
   Oddly enough, yes, this reduces the transmission of airborne infection.    
   
6. How long can influenza viruses survive outside a host?    
   At room temperature, with moderate humidity, these viruses can live 24 to 48 hours on steel and plastic, and 8 to 12 hours on cloth and facial tissues.    
   
7. How can I protect elderly clients and other immunocompromised clients from health care associated infections?    
   Standard precautions should be used with all patients to prevent the spread of pathogens.    
   

 

Important Terminology in Infection Control

1. airborne precautions (ehr-born pree-kaw-shuns)
   measures taken to prevent the spread of diseases transmitted from an infected person by pathogens propelled through the air on particles smaller than 5 µm in size to a susceptible person’s eyes, nose, or mouth
2. antibody (an-tih-bah-dee)    
   a type of protein the immune system produces to neutralize a threat of some kind, such as an infecting organism, a chemical, or some other foreign body    
3. antimicrobial (an-tih-my-crow-bee-uhl)       
   able to destroy or suppress the growth of pathogens and other micro-organisms    
   
4. antiseptic (an-tih-sep-tick)       
   a substance that reduces the number of pathogens present on a surface    
   
5. asepsis (ae-sep-sis)        
   methods used to assure that an environment is as pathogen-free as possible    
   
6. aseptic (ae-sep-tick)      
   as pathogen-free as possible    
   
7. bacteriostasis (back-teer-ee-oh-stay-sis)        
   the inhibition of further bacterial growth    
   
8. chlorhexidine (klor-hex-uh-dine)    
   an antibacterial compound with substantial residual activity that is used as a liquid antiseptic and disinfectant    
   
9. contact precautions (kon-takt pree-kaw-shuns)       
   measures taken to prevent the spread of diseases transmitted by the physical transfer of pathogens to a susceptible host’s body surface    
   
10. contamination (kuhn-tam-eh-nay-shun)    
    the process of becoming unsterile or unclean    
    
11. disinfectant (dis-in-feck-tunt)      
    any chemical agent used to destroy or inhibit the growth of harmful organisms    
    
12. droplet precautions (drop-let pree-kaw-shuns)        
    measures taken to prevent the spread of diseases transmitted from an infected person by pathogens propelled through the air on particles larger than 5 µm in size to a susceptible person's eyes, nose, or mouth    
    
13. endemic (en-dem-mick)        
    prevalent in or characteristic of a particular environment    
    
14. endogenous (en-dodge-uh-nuss)       
    produced within an organism or system rather than externally caused    
    
15. epidemic (ep-ih-dem-mick)    
    extremely prevalent or widespread    
    
16. exogenous (ecks-odge-uh-nuss)      
    externally caused rather than produced within an organism or system
17. flora (flawr-uh)       
    the aggregate of bacteria, fungi, and other micro-organisms normally found in a particular environment, such as the gastrointestinal tract or the skin    
    
18. hyperendemic (high-purr-en-dem-mick)       
    at an especially high level of continued incidence in a population    
    
19. immunosuppression (im-you-noe-suh-presh-uhn)   
    the inhibition of the body’s protective response to pathogenic invasion, usually as a result of disease, drug therapy, or surgery    
    
20. infection (in-feck-shun)     
    invasion and proliferation of pathogens in body tissues     
    
21. isolation (eye-suh-lay-shun)      
    the separation of an infected person from others for the period of communicability of a particular disease    
    
22. latex (lay-tecks)       
    a milky fluid produced by rubber trees that is processed into a variety of products, including gloves used for patient care
23. medical asepsis (med-ih-kull ae-sep-sis)       
    infection-control practices common in healthcare, such as basic hand-washing
24. methicillin-resistant Staphylococcus aureus (MRSA) (meth-ih-sill-uhn ree-zis-tunt staff-flow-kock-uuhs orr-ee-uhs [murs-uh])      
    a strain of the bacterium Staphylococcus aureus that has become resistant to the antibacterial action of the antibiotic methicillin, a form of penicillin    
    
25. pathogen (path-uh-jin)       
    any disease-producing agent, especially a virus, bacterium, or fungus    
    
26. personal protective equipment (PPE) (purs-uh-nuhl pruh-teck-tiv ee-kwip-munt [pee-pee-ee])     
    devices used to protect employees from workplace injuries or illnesses resulting from biological, chemical, radiological, physical, electric, mechanical, or other workplace hazards    
    
27. pneumococcal (noo-muh-kock-uhl)    
    pertaining to or caused by pneumococci, organisms of the species Streptococcus pneumoniae, a common cause of pneumonia and other infectious diseases    
    
28. portal of exit (pôrdl əv eksət)         
    the route by which microorganisms exit the reservoir on their way to a susceptible host    
    
29. Portal of entry (pôrdl əv entrē)   
    the route by which microorganisms enter the host    
    
30. reservoir (rezərˌvwär)    
    the place where microorganisms thrive    
    
31. retrovirus (reh-troe-vie-ruhs)        
    any of a large group of RNA-based viruses that tend to infect immunocompromised individuals, including the human immunodeficiency virus and many cancer-causing viruses    
    
32. sepsis (sep-sis)    
    the presence in blood or other tissues of pathogens or their toxins    
    
33. standard precautions (stan-durd pree-kaw-shuns)      
    measures designed to prevent the transmission of organisms and used for all patients in healthcare facilities regardless of diagnosis or infection status
34. staphylococcus (staff-flow-kock-uuhs)    
    a genus of gram-positive bacteria that are potential pathogens, causing local lesions and serious opportunistic infections
35. surgical asepsis (surr-jik-kuhl ae-sep-sis)      
    techniques used to destroy all pathogenic organisms, also called sterile technique
36. transmission-based precautions (trans-mish-uhn pree-kaw-shuns)      
    measures taken to prevent the spread of diseases from people suspected to be infected or colonized with highly transmissible pathogens that require measures beyond standard precautions to interrupt transmission, specifically, airborne, droplet, and contact precautions    
    
37. vancomycin-resistant Staphylococcus aureus (VRSA) (van-koh-my-sin ree-zis-tunt staff-flow-kock-uuhs orr-ee-uhs [vurs-uh])      
    a strain of the bacterium Staphylococcus aureus that has become resistant to the antibacterial action of the antibiotic vancomycin    
    
38. Virulence (vir(y)ələns)   
    the ability of a microorganism to cause disease    

References

1. Alsubaie, S., bin Maither, A., Alalmaei, W., Al-Shammari, A. D., Tashkandi, M., Somily, A. M., Alaska, A., & BinSaeed, A. A. (2013). Determinates of hand hygiene noncompliance in intensive care units. American Journal of Infection Control 41(2): 131-135.
2. Berman, A., Snyder, S., & Frandsen, G., (2016). Kozier & Erb’s fundamentals of nursing: Concepts, processes and practice (10th ed.) .New York, NY: Pearson Education.
3.  Centers for Disease Control and Prevention. (2017). Hand hygiene in healthcare settings. Retrieved November 14, 2017.
4.   Centers for Disease Control and Prevention. (2017). Healthcare-associated infections (HAI) Retrieved November 17, 2017. 
5.  Centers for Disease Control and Prevention. (2016). Guide to infection prevention for outpatient settings: Minimum expectations for safe care. Retrieved November 14, 2017. 
6. Centers for Disease Control and Prevention. (2007). Guidelines for isolation precautions: Preventing transmission of infectious agents in health care settings. Retrieved October 17, 2017
7. Centers for Disease Control and Prevention. (2014). Latex allergy: A prevention guide. Retrieved November 14, 2017. 
8. Centers for Disease Control and Prevention. Testing health care workers. Retrieved October 19, 2017. .   
9. DeWit, S., Dalred, C., Stromberg, H., (2017). Medical surgical nursing: Concepts and practice (3rd ed.). St. Louis, MO:  Elsevier.
10. Federal Drug Administration. (2016) Safely Using Needles and Sharps, at Home at Work, and at Travel. Retrieved November 15, 2017
11. Gould, D.,Moralejo, D., Drey, N., Chudleigh, J., Taliaard, M. (2017). Interventions to improve hand hygiene compliance in patient care. Cochrane Database Systematic Review, Sept 1 (9). doi: 10.1002/14651858.CD005186.pub4
12. Occupational Safety & Health Administration.(2013). (Lack of) universal precautions. Retrieved November 17, 2017.
13. Oey, M., Armellion, D. & Farber, B. (2015).  Evaluation of isolation compliance using real time video in critical care. Open Forum Infectious Diseases 2(1). 1101.
14. Pincock, T., Bernstein, P., Warthman, S., & Hols,. E. (2012). Bundling hand hygiene interventions and measurement to decrease health care-associated infections. American Journal of Infection Control, 40, S18-27.
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16. Stats, B., Dai, H., Hofmann, D. & Milkman, K. (2016). Motivation process compliance through individual electronic monitoring: An empirical examination of hand hygiene in healthcare. Management Science 63(5). 1563-1585. doi.org/10.1287/mnsc.2015.2400
17. The Joint Commission. (2017). 2017 National patient safety goals: Goal 7 (healthcare associated infections). Retrieved November 15, 2017.
18. US Environmental Protection Agency (EPA).(2004). Community options for safe needle disposal. Retrieved November 16, 2017.

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